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Q and A - 12 February

Posted on 12 February 2018

The NDIA advises the Q and A statement posted on 22 December 2017, regarding the payment of Medicare and private health gap fees was incorrect. We apologise for any confusion the statement caused, and we have removed it.

No. The NDIS is not designed to fund supports more appropriately funded or provided by the health system. You cannot use your NDIS funds to pay Medicare gap fees. As an NDIS participant, you cannot claim under both systems for the same support. The NDIS Act and Rules provide guidance for what is funded under the Scheme. Basically, a support the NDIS pays for is not claimable against any other Commonwealth Program such as Medicare.

No. This is not correct. The NDIA develops and approves plan budgets to cover the full cost of supports, for example, psychology services, where they are considered reasonable and necessary for a participant.

The decision as to what capacity building supports or therapy would be deemed reasonable and necessary takes into account the responsibilities of the health system and services already available to the participant.

Once plan supports are approved, the participant can use those supports as described in the plan. Therapy may be described generally (e.g. "Therapy up to the value of $X") in a budget so it can be used flexibly within that budget or it may be described specifically (for example, 1 session of psychology/therapy per week).

NDIA plan budgets are developed to cover the full cost of supports (e.g. physiotherapy or OT services to build function) where these are considered reasonable and necessary for the participant. As a result, you should not have to pay a "gap" fee.

Participants should not make claims under private health insurance policies for 'reasonable and necessary' supports in their plan they intend to claim from the NDIS. Participants may choose to use private health insurance to fund services and treatments not funded in their NDIS plan.

In rare cases, where a support being delivered may be claimable under either the participant's plan or private health insurance, the participant may choose whether to use NDIS funds or to make a claim under their private health insurance but they cannot make a claim under both in respect to the same support.

No. NDIS funded supports do not replace the role of families and carers. This means a family member won't be paid for acting as a support worker to another family member with disability, except where it has been approved for a strict time-limit due to proof of exceptional circumstances.

If you click on "Find registered service providers" then scroll down the page, you will see links to all current NDIS registered providers. There are files for each state and territory and you can search by provider name or by provider registration. Every three months we update these lists. The next update is on Wednesday, 28 February 2018 and will be published mid-March.